Demoule Alexandre, Molinari Nicolas, Jung Boris, Prodanovic Hélène, Chanques Gerald, Matecki Stefan, Mayaux Julien, Similowski Thomas, Jaber Samir
INSERM, UMRS1158 Neurophysiologie respiratoire expérimentale et clinique, Sorbonne Universités, UPMC Univ Paris 06, Paris, France.
Intensive Care Unit and Respiratory Division (Département "R3S"), Groupe Hospitalier Pitié-Salpêtrière Charles Foix, AP-HP, 75013, Paris, France.
Ann Intensive Care. 2016 Dec;6(1):75. doi: 10.1186/s13613-016-0179-8. Epub 2016 Aug 5.
In intensive care unit (ICU) patients, diaphragmatic dysfunction (DD) can occur on admission or during the subsequent stay. The respective incidence of these two phenomena has not been previously studied in humans. The study was designed to describe temporal trends in diaphragm function in mechanically ventilated (MV) patients.
Ancillary study of a prospective, 6-month, observational cohort study conducted in two ICUs. MV patients were studied within 24 h following intubation (day-1) and every 48-72 h thereafter. Diaphragm function was assessed by twitch tracheal pressure (Ptr,stim) in response to bilateral anterior magnetic phrenic nerve stimulation. Diaphragm dysfunction was defined as Ptr,stim < 11 cmH2O. Patients who received MV for at least 5 days were retained, and the first and the last measures were analysed.
Forty-three patients were included. Overall, 79 % of patients developed DD at some point during their ICU stay: 23 (53 %) patients presented DD on initiation of mechanical ventilation, 14 (33 %) of whom had persistent DD, while diaphragm function improved in 9 (21 %). Among the remaining 20 (47 %) patients who did not present DD on initiation of MV, 11 (26 %) developed DD during the ICU stay, while 9 (21 %) did not. Mortality was higher in patients with DD either on initiation of mechanical ventilation or during the subsequent ICU stay than in those who never developed DD (35 vs. 0 %, p = 0.04). Duration of MV was higher in patients with DD on initiation of MV that subsequently persisted than in patients who never exhibited diaphragm dysfunction (18 vs. 5 days, p = 0.04). Factors associated with a change in Ptr,stim were: age [linear coefficient regression (Coeff.) -0.097, standard error (SD) 0.047, p = 0.046], PaO2/FiO2 ratio (Coeff. 0.014, SD 0.006, p = 0.0211) and the proportion of the time under MV with sedation (per 10 %, Coeff. -5.359, SD 2.451, p = 0.035).
DD is observed in a large majority of MV patients ≥5 days at some point of their ICU stay. Various patterns of DD are observed, including DD on initiation of mechanical ventilation and ICU-acquired DD. Trial registration clinicaltrials.gov Identifier # NCT00786526.
在重症监护病房（ICU）患者中，膈肌功能障碍（DD）可能在入院时或随后的住院期间出现。此前尚未在人类中对这两种现象的各自发生率进行研究。本研究旨在描述机械通气（MV）患者膈肌功能的时间趋势。
对在两个ICU进行的一项为期6个月的前瞻性观察队列研究的辅助研究。MV患者在插管后24小时内（第1天）以及此后每48 - 72小时进行研究。通过对双侧膈神经前磁刺激的气管抽搐压力（Ptr,stim）评估膈肌功能。膈肌功能障碍定义为Ptr,stim < 11 cmH₂O。接受MV至少5天的患者被纳入，分析首次和末次测量结果。
纳入43例患者。总体而言，79%的患者在ICU住院期间的某个时间点出现DD：23例（53%）患者在机械通气开始时出现DD，其中14例（33%）持续存在DD，而9例（21%）患者的膈肌功能有所改善。在其余20例（47%）机械通气开始时未出现DD的患者中，11例（26%）在ICU住院期间出现DD，而9例（21%）未出现。机械通气开始时或随后的ICU住院期间出现DD的患者的死亡率高于从未发生DD的患者（35%对0%，p = 0.04）。机械通气开始时出现DD且随后持续存在的患者的MV持续时间高于从未出现膈肌功能障碍的患者（18天对5天，p = 0.04）。与Ptr,stim变化相关的因素有：年龄[线性系数回归（Coeff.）-0.097，标准误差（SD）0.047，p = 0.046]、PaO₂/FiO₂比值（Coeff. 0.014，SD 0.006，p = 0.0211）以及使用镇静剂时MV的时间比例（每增加10%，Coeff. -5.359，SD 2.451，p = 0.035）。
在大多数MV时间≥5天的ICU患者中，在其住院期间的某个时间点观察到DD。观察到DD的各种模式，包括机械通气开始时的DD和ICU获得性DD。试验注册ClinicalTrials.gov标识符# NCT00786526。
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